Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 – 12/31/2018 Health Net of CA: Blue & Gold HMO Coverage for: All Covered Members | Plan Type: HMO

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The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.healthnet.com/uc or call 1-800-

539-4072. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.dol.gov/ebsa/healthreform or www.healthnet.com/uc or you can call 1-800-539-4072 to request a copy.

Important Questions Answers Why This Matters: What is the overall deductible? $0. See the Common Medical Events chart below for your costs for services this plan covers.

Are there services covered before you meet your deductible?

No. You will have to meet the deductible before the plan pays for any services.

Are there other deductibles for specific services?

No. You don’t have to meet deductibles for specific services.

What is the out-of-pocket limit for this plan?

$1,000 member / $3,000 family each calendar year.

The out-of-pocket limit is the most you could pay in a year for covered services. If you have family members in this plan, they have to meet their own out-of-pocket limit until the overall family out-of-pocket limit has been met.

What is not included in the out-of-pocket limit?

Premiums and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–of–pocket limit.

Will you pay less if you use a network provider?

Yes. For a list of preferred providers, see www.healthnet.com/uc or call 1-800-539-4072.

This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Do you need a referral to see a specialist? Yes. Requires written prior authorization. This plan will pay some or all of the costs to see a specialist for covered services but only if

you have a referral before you see the specialist.

2 of 6 * For more information about limitations and exceptions, see the plan or policy document at www.healthnet.com/uc DW7/04E/XOF/AD3

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important

Information In-network Provider (You will pay the least)

Out-of-Network Provider

(You will pay the most)

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness $20/visit Not covered –––––––––––none–––––––––––

Specialist visit $20/visit Not covered Requires prior authorization.

Preventive care/screening/ immunization No charge Not covered

You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.

If you have a test

Diagnostic test (x-ray, blood work) No charge Not covered Requires referral.

Imaging (CT/PET scans, MRIs) No charge Not covered Requires prior authorization.

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.healthnet.com/uc

Generic drugs $5/retail order $10/mail order Not covered Supply/order: up to 30 day (retail); 35-90 day (mail),

except where quantity limits apply. Prior Authorization is required for select drugs. May use select UC or CVS pharmacies to obtain up to a 90 day supply maintenance medications. If you buy a brand name drug that has a generic equivalent, you pay the difference in cost between the brand name and generic drug plus copay or coinsurance for the generic.

Preferred brand drugs $25/retail order $50/mail order Not covered

Non-preferred brand drugs $40/retail order $80/mail order Not covered

Specialty drugs

Self injectables- $20/order

Refer to the recommended drug list for other drugs

considered specialty

Not covered Prior authorization is required for select drugs. Quantity limits may apply to select drugs. Supply/order: up to a 30 day supply filled by specialty pharmacy

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center) $100/procedure Not covered Requires prior authorization.

Physician/surgeon fees No charge Not covered –––––––––––none–––––––––––

3 of 6 * For more information about limitations and exceptions, see the plan or policy document at www.healthnet.com/uc DW7/04E/XOF/AD3

Common Medical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important

Information In-network Provider (You will pay the least)

Out-of-Network Provider

(You will pay the most)

If you need immediate medical attention

Emergency room care $75/visit $75/visit Cost sharing waived if admitted to the hospital. Emergency medical transportation No charge No charge –––––––––––none–––––––––––

Urgent care $20/visit $20/visit Cost sharing waived if admitted to the hospital.

If you have a hospital stay

Facility fee (e.g., hospital room) $250/stay Not covered Requires prior authorization.

Physician/surgeon fees No charge Not covered –––––––––––none–––––––––––

If you need mental health, behavioral health, or substance abuse services

Outpatient services Visits 1-3 $0 copay Visits 4+ $20 copay per visit

Covered in emergencies only, at in-network level

Benefits provided by Optum. Call 1-888-440-8225 or visit www.liveandworkwell.com. Non-routine services require pre-authorization. Copay waived for Intensive outpatient and Partial Hospitalization.

Inpatient services $250 copay per admission Covered in emergencies only, at in-network level

Benefits provided by Optum. Call 1-888-440-8225 or visit www.liveandworkwell.com.

If you are pregnant

Office visits No charge Not covered Cost sharing does not apply to preventive services. Childbirth/delivery professional services No charge Not covered Coverage includes abortion services.

Childbirth/delivery facility services $250/stay Not covered Coverage includes abortion services.

If you need help recovering or have other special health needs

Home health care No charge Not covered Requires prior authorization. Rehabilitation services $20/visit Not covered Requires prior authorization.

Habilitation services Not covered Not covered –––––––––––none–––––––––––

Skilled nursing care No charge Not covered Limited to 100 days per calendar year. Requires prior authorization.

Durable medical equipment No charge Not covered Requires prior authorization.

Hospice services No charge Not covered Requires prior authorization.

If your child needs dental or eye care

Children’s eye exam $20/visit Not covered No charge if exam takes place during preventive periodic health evaluation.

Children’s glasses Not covered Not covered –––––––––––none––––––––––– Children’s dental check-up Not covered Not covered –––––––––––none–––––––––––

4 of 6 * For more information about limitations and exceptions, see the plan or policy document at www.healthnet.com/uc DW7/04E/XOF/AD3

Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

• Cosmetic surgery • Dental care (Adult) • Glasses

• Habilitation services • Long-term care • Non-emergency care when traveling outside the

U.S.

• Private-duty nursing • Routine foot care • Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

• Acupuncture– Your group has purchased an acupuncture benefit rider. When you use a practitioner in the American Specialty Health Plan network, acupuncture is covered with a copayment of $20/visit up to 24 visits per calendar year combined with Chiropractic. You may self-refer for the initial visit; subsequent visits require prior authorization.

• Bariatric surgery

• Chiropractic care– Your group has purchased a chiropractic benefit rider. When you use a practitioner in the American Specialty Health Plan network, chiropractic care is covered with a copayment of $20/visit up to 24 visits per calendar year combined with Acupuncture. You may self-refer for the initial visit; subsequent visits require prior authorization.

• Hearing aids (limited to 2 devices every 36 months with a $2,000 benefit maximum)

• Infertility services • Routine eye care (Adult)

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov.Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

5 of 6 * For more information about limitations and exceptions, see the plan or policy document at www.healthnet.com/uc DW7/04E/XOF/AD3

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Health Net’s Customer Contact Center at 1-800-522-0088, submit a grievance form through www.healthnet.com, or file your complaint in writing to, Health Net Appeals and Grievance Department, P.O. Box 10348, Van Nuys, CA 91410-0348. For information about group health care coverage subject to ERISA, contact the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444 (EBSA (3272) or www.dol.gov/ebsa/healthreform. If you have a grievance against Health Net, you can also contact the California Department of Managed Health Care, at 1-800-HMO-2219 or www.hmohelp.ca.gov. For information about group health care coverage subject to ERISA, contact the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444 (EBSA (3272) or www.dol.gov/ebsa/healthreform Does this plan provide Minimum Essential Coverage? Yes If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-800-539-4072. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-539-4072. Chinese (中文): 如果需要中文的帮助，请请打这个号码1-800-539-4072. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-539-4072.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

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The plan would be responsible for the other costs of these EXAMPLE covered services. DW7/04E/XOF/AD3

Peg is Having a Baby (9 months of in-network pre-natal care and a

hospital delivery)

Mia’s Simple Fracture (in-network emergency room visit and follow

up care)

Managing Joe’s type 2 Diabetes (a year of routine in-network care of a well-

controlled condition)

The plan’s overall deductible $0 Specialist copayment $20 Hospital (facility) copayment $250 Other copayment $20 This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,800

In this example, Peg would pay:

Cost Sharing Deductibles $0Copayments $300Coinsurance $0

What isn’t covered Limits or exclusions $60The total Peg would pay is $360

The plan’s overall deductible $0 Specialist copayment $20 Hospital (facility) copayment $250 Other copayment $20 This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $7,400

In this example, Joe would pay:

Cost Sharing Deductibles $0Copayments $700Coinsurance $0

What isn’t covered Limits or exclusions $60The total Joe would pay is $760

The plan’s overall deductible $0 Specialist copayment $20 Hospital (facility) copayment $250 Other copayment $20 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,500

In this example, Mia would pay:

Cost Sharing Deductibles $0 Copayments $400 Coinsurance $0

What isn’t covered Limits or exclusions $0 The total Mia would pay is $400

About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Health Net Life Insurance Company (“Health Net”) complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Health Net does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Health Net: • Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats).

• Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages.

If you need these services, contact Health Net's Customer Contact Center at:

On Exchange/Covered California 1-888-926-4988 (TTY: 711) Off Exchange 1-800-522-0088 (TTY: 711)

If you believe that Health Net has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by calling the number above and telling them you need help filing a grievance; Health Net's Customer Contact Center is available to help you. You can also file a grievance by mail, fax or online at: Health Net Life Insurance Company Appeals & Grievances P.O. Box 10348 Van Nuys, CA 91410-0348

Fax: 1-877-831-6019

Online: healthnet.com

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019 (TDD: 1-800–537–7697).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

In addition to the State of California nondiscrimination requirements (as described in benefit coverage documents), Health Net of California, Inc. (“Health Net”) complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Health Net does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Health Net: • Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats).

• Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages.

If you need these services, contact Health Net's Customer Contact Center at:

On Exchange/Covered California 1-888-926-4988 (TTY: 711) Off Exchange 1-800-522-0088 (TTY: 711)

If you believe that Health Net has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by calling the number above and telling them you need help filing a grievance; Health Net's Customer Contact Center is available to help you. You can also file a grievance by mail, fax or online at: Health Net of California, Inc. P.O. Box 10348 Van Nuys, CA 91410-0348

Fax: 1-877-831-6019

Online: healthnet.com

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019 (TDD: 1-800–537–7697).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.